A list of the most recent deficiencies for Benedictine Manor of Lacrosse. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-11 | 2024-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-11 | 2024-02-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-11 | 2024-02-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-01-11 | 2024-02-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-11 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-02-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-11 | 2024-02-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-11 | 2024-02-06 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-01-10 | 2024-02-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-10 | 2024-02-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-25 | 2023-11-20 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-09 | 2023-02-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-12-08 | 2023-01-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-08 | 2023-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2023-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2023-01-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-12-09 | 2023-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-09 | 2023-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-09 | 2023-01-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-10-05 | 2022-04-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-28 | 2022-01-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-07 | 2021-11-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-10-07 | 2021-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-07 | 2021-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-05 | 2021-11-17 | N |
